Healthcare Provider Details

I. General information

NPI: 1194365742
Provider Name (Legal Business Name): RILEY CLARKE HAWKINS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2020
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 LIBERTY ST SE
SALEM OR
97302-4345
US

IV. Provider business mailing address

2244 NW OVERTON ST APT 3
PORTLAND OR
97210-2989
US

V. Phone/Fax

Practice location:
  • Phone: 503-589-0565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA195908
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: